Analysis of factors associated with depressive symptoms in stroke patients based on a national cross-sectional study

Post-stroke depression is commonly experienced by stroke survivors and has a significant negative impact on the physical, cognitive, and social functioning of those affected. This study aims to investigate the prevalence of depressive symptoms and their associated factors in Chinese stroke patients. Research samples were selected from the China Health and Retirement Longitudinal Study 2018 survey. Depression was evaluated using the 10-item Center for Epidemiological Studies Depression Scale, with a score ≥ 10 defined as depression. Univariate and multivariable analyses were performed to examine the associations of depressive symptoms with demographics, family relationships, health status, and lifestyle. A total of 963 stroke patients were included and 57.8% of them had depressive symptoms. Depressive symptoms were significantly associated with female sex (OR 1.762, 95% CI 1.235–2.514), lower education level (non-formal education: OR 2.148, 95% CI 1.235–3.737, primary to secondary school education: OR 1.964, 95% CI 1.272–3.033), dissatisfaction with spouse (OR 1.912, 95% CI 1.075–3.401), dissatisfaction with life (OR 1.779, 95% CI 1.080–2.931), dissatisfaction with health (OR 1.592, 95% CI 1.138–2.226), pain (OR 1.392, 95% CI 1.005–1.928) and abnormal sleep (OR 1.557, 95% CI 1.126–2.152). The findings suggest the need for regular depression screening and evaluation after a stroke, and that a well-functioning support system, effective health management, and lifestyle modifications could potentially improve the mental state of stroke patients.


Family relationships and depressive symptoms of stroke patients
Most of the patients had 1-2 children (67.4%) and were cared for by family members (69.9%).The vast majority of patients were satisfied with their children (93.6%), 76.7% were satisfied with their spouse, and 84.3% were satisfied with their life.
The univariate analysis showed that family care, relationships with children and spouses, and life satisfaction were significantly associated with depressive symptoms in stroke patients.Patients without family caregivers had a higher proportion of depressive symptoms than those with (63.4% vs. 55.4%,P < 0.05).Patients who were Table 1.Demographic characteristics and depressive symptoms of stroke patients in China.*There is statistical significance between 'high school and above' and 'primary to secondary school' , between 'high school and above' and 'no formal education' , and between 'primary to secondary school' and 'no formal education' .dissatisfied with their children were more likely to have depressive symptoms than those who were satisfied (81.5% vs. 56.2%,P < 0.05).The proportion of depressive symptoms was higher in patients who were dissatisfied with their spouse than that of those who were satisfied with their spouse (80.8% vs. 53.7%,P < 0.05), and who did not have a spouse (80.8% vs. 64.0%,P < 0.05).Compared with patients who were satisfied with their life, patients who were dissatisfied were more likely to have depressive symptoms (80.8% vs. 53.6%,P < 0.05) (Table 2).

Health status and depressive symptoms of stroke patients
Regarding health status, half of patients (52.9%) rated their health as being poor while only 8.6% rated their health as being good.Half of patients (50.5%) were satisfied with their health and half (49.5%) were not.The majority of patients (79.1%) had two or more co-morbid conditions.A total of 68.3%, 26.3%, 38.9% and 17.2% had hypertension, diabetes mellitus, heart disease, and lung disease, respectively.Most of the patients (69.8%) suffered from physical pain, and 39.1% were able to work normally.The univariate analysis showed that self-rated health, health satisfaction, co-morbid conditions, heart disease, lung disease, physical pain, and work ability were significantly associated with depressive symptoms in stroke patients.Specifically, the proportion of depressive symptoms was higher in patients with poor self-rated health than that of those with fair (66.2% vs. 50.9%,P < 0.05) and good self-rated health (66.2% vs. 37.3%, P < 0.05).Patients who were dissatisfied with their health were more likely to have depressive symptoms than patients who were satisfied (69.6% vs. 46.3%,P < 0.05).Patients with two or more co-morbid conditions had a higher proportion of depressive symptoms than those with only one (61.4% vs. 44.4%,P < 0.05) and without (61.4% vs. 44.0%,P < 0.05).Patients who had heart disease (64.8% vs. 53.4%,P < 0.05), lung disease (66.9% vs. 56.0%,P < 0.05), and physical pain (64.3% vs. 43.0%,P < 0.05) were more likely to experience depressive symptoms.Patients who were unable to work long hours (65.8% vs. 47.7%,P < 0.05) and work at all (62.6% vs. 47.7%,P < 0.05) had a higher proportion of depressive symptoms compared to those who were able to work normally (Table 3).

Lifestyle and depressive symptoms of stroke patients
Most stroke patients did not drink alcohol (70.8%), did not smoke (74.7%), and had physical activities (86.9%), while only half (54.2%) participated in social activities.Most of the patients (70.2%) had normal sleep, and 69.3% were receiving stroke treatment.
The univariate analysis showed that patients with abnormal sleep had a higher proportion of depressive symptoms than those with normal sleep (69.3% vs. 53.0%,P < 0.05).Patients who were under stroke treatment were more likely to have depressive symptoms than those who were not (60.3% vs. 52.4%,P < 0.05) (Table 4).

Multi-variable analysis of depressive symptoms of stroke patients
The regression analysis further confirmed the significant associations between sex, educational level, relationships with spouse, life satisfaction, health satisfaction, physical pain, sleep duration, and depressive symptoms.Females Table 2. Family relationships and depressive symptoms of stroke patients in China.*The group '0' were not included in the chi-square test.† The group "no child" were not included in the chi-square test.‡ There is statistical significance between 'satisfied' and 'dissatisfied' , between 'dissatisfied' and 'no spouses' .5).Further stratified analyses by gender showed that, in males, patients with primary to secondary school education tended to report depressive symptoms compared with those with high school education and above (OR 2.252, 95% CI 1.359-3.730),and patients who were not satisfied with their spouse (OR 2.559, 95% CI 1.116-5.869)as well as health (OR 1.722, 95% CI 1.115-2.661)had a higher likelihood of experiencing depressive symptoms than those who were (Supplementary Table 1).In females, patients aged 60 years or older were less likely to report depressive symptoms than those aged 45-59 years old (OR 0.505, 95% CI 0.285-0.893),and patients without family caregivers (OR 1.720, 95% CI 1.035-2.861)and with abnormal sleep (OR 1.882, 95% CI 1.137-3.116)were more likely to report depressive symptoms (Supplementary Table 2).Table 3. Health status and depressive symptoms of stroke patients in China.*There is statistical significance between 'good' and 'poor' , between 'fair' and 'poor'; † There is statistical significance between '0' and '2 ~ ' , between '1' and '2 ~ '; ‡ There is statistical significance between 'work normally' and 'unable to work long hours' , between 'work normally' and 'unable to work at all ' .

Discussion
Nearly 60% of stroke patients in the study reported experiencing depressive symptoms.In the univariate analysis, significant associations were found between demographic characteristics, family relationships, health status, lifestyle, and depressive symptoms.The results of multivariable analysis further showed that female sex, lower education level, dissatisfaction with the spouse, dissatisfaction with life, dissatisfaction with health, physical pain, and abnormal sleep were significantly associated with depressive symptoms in Chinese stroke patients.This study showed that the prevalence of depressive symptoms among stroke patients was 57.8%, which was higher than that previously reported in China [24][25][26][27] and other countries 28,29 .In two hospital-based surveys in China 24,25 , the proportions of stroke patients with depression were 41.1% and 31.4%,respectively.This discrepancy is partly due to the use of different diagnostic instruments.In most studies 24,25,27 , depression was clinically diagnosed according to International Classification of Diseases (ICD) codes, whereas our study used the CESD-10, a self-rated scale, to assess depressive symptoms, which might have identified more sub-threshold or mild cases.When different studies used the same diagnostic instrument, the reported prevalence rates were closer.Sit et al. investigated the prevalence of post-stroke depression using the CESD-20 items in Hong Kong, China, and reported a prevalence of 69% and 48% at 48 h and 6 months after stroke, respectively 30 .On another note, ignoring the classification of different stroke types and stroke stages may also result in differences in depression prevalence.However, lower prevalence rates in the United States (23.29%) 28 , Finland, and Sweden (12.8%) 29 might be due to greater awareness of mental health and more preventive and treatment measures for depression in these countries.
Our analysis showed that female sex was significantly associated with depressive symptoms.This is consistent with previous studies 27,28,[31][32][33] , including two large prospective studies from the United Kingdom and Denmark 32,33 .However, there is still ongoing debate in the literature regarding whether females are more susceptible to post-stroke depression than males.In a systematic analysis by Ryck et al., of 21 studies reviewed, only 7 studies identified female sex as a risk factor for post-stroke depression 34 .According to Wang et al., the association between sex and depression in stroke patients might be influenced by the stage of depression being evaluated.In their study, they observed that female sex was an independent risk factor for post-stroke depression in the acute stroke phase instead of the chronic phase 27 .The results of our univariate and multi-variable analyses showed that stroke patients with lower education levels had a higher probability of having depressive symptoms.Likewise, a cohort study indicated that education level (high school or above) was a protective factor for post-stroke depression at 3 months after stroke event 27 .
Our study revealed that family support and relationships play crucial roles in overcoming depression after a stroke.In the univariate analysis, we found that stroke patients without family caregivers had a higher proportion of being depressed than those with family caregivers.Moreover, we observed that stroke patients who were dissatisfied with their children in the univariate analysis and dissatisfied with their spouse and life in both univariate and multi-variable analyses were more likely to experience depressive symptoms.These findings agree with a population-based study that identified family support as a major protective factor against depression among Chinese elderly 35 .Stroke patients need the support of their family members during the recovery process, especially if they have disabilities and dysfunctions.A well-established family support system can provide life and emotional support to stroke patients and help them deal with psychological stress.
Self-rated health is a subjective measure of an individual's overall physical, psychological, social, and functional status 36 .In stroke patients, self-rated health can reflect the individual's adjustment and recovery conditions after a stroke event 37 .Our study reported a significant link between poor self-rated health and depressive symptoms in the univariate analysis.Likewise, Araújo et al. identified emotional functioning as a correlate of an individual's self-rated health after stroke in the chronic phase 38 .In addition, we also observed a significant association between health dissatisfaction and depressive symptoms in stroke patients.Multi-morbidity is increasingly common and has a bi-directional relationship with depression 39 .Univariate analysis results indicated that depressive symptoms in stroke patients were significantly associated with co-morbid conditions (two or more) and the type of chronic conditions, specifically heart disease and lung disease.Similarly, Jørgensen et al. found that a high level of somatic comorbidity was a significant risk factor for depression in patients with and without stroke.Additionally, their study identified diabetes as an important risk factor for depression 33 .Consistent with previous literature 40 , our study confirmed the association between physical pain and depressive symptoms in Chinese stroke patients.Consistent with previous studies 20 , stroke survivors with inability to work were more likely to be depressed.One possible reason for this is that stroke patients who were unable to work may be more concerned about their economic stability and were prone to depression 41 .
Our univariate and multi-variable analyses revealed a significant association between sleep duration and depressive symptoms.Similar relations between insomnia, sleep disorder, and depression were found in previous studies 24,28 .Unexpectedly, our univariate analysis results showed that stroke patients who were under stroke treatment were more likely to experience depressive symptoms than those who were not, although this association became insignificant in multivariable analysis.This might be because individuals who have more concerns about their disability and functional status are more likely to seek stroke treatment 21 .
The gender-stratified analyses conducted in our study unveiled significant discrepancies in the factors influencing depressive symptoms among males and females.Notably, among males, education level, satisfaction with one's spouse, and satisfaction with one's health status emerged as prominent factors, while among females, age, family caregivers, and sleep patterns appeared to be key contributors.However, it is worth noting that a recent study assessing gender differences in the influence of the five most established risk factors, including functional dependency, a history of pre-stroke depression, social support, stroke severity, and cognitive impairment, found no gender-specific effects 42 .This suggests a wider relevance of these risk factors across genders.Nevertheless, the impact of gender in the context of stroke and depression warrants further investigation and highlights the need for more gender-specific studies in this area.
This study has several implications for health policy and practice.First, our study reported a high prevalence of depressive symptoms (57.8%), suggesting the mental health status of stroke patients is an urgent attention and resolution in China.Second, female and less educated stroke patients were found to be more likely to experience depressive symptoms, highlighting the need for routine screening and assessment of depression among these high-risk groups.Third, our findings underscore the significance of a well-functioning family support system for stroke patients' mental health and well-being, as demonstrated by the significant correlation between family relationships and depressive symptoms.Fourth, given the correlation between health status and depressive symptoms, our study underscores the importance of pain management and health management in clinical practice in stroke patients.Finally, our study found that lifestyle, particularly sleep duration, was significantly associated with depressive symptoms, suggesting that adjusting sleep habits might improve depression status in stroke patients.
One of the strengths of this study is that it estimated the prevalence and associated factors of depressive symptoms among stroke patients in China using a nationwide dataset.Another strength of this study is that, besides social demographic characteristics and health status, modifiable factors like family relationships and lifestyle were investigated in this study for their potential association with depressive symptoms, which could help in planning interventions.However, our study has several limitations that need to be considered.First, we recognized that our study evaluated depressive symptoms by using CESD-10, rather than diagnosing clinical depression with ICD codes.The use of this method may limit our ability to directly compare our results with previous research that examined diagnosed clinical depression.Second, several prospective studies with large sample sizes showed that stroke severity and pre-stroke depression were strong predictors of depression in stroke patients 32,33 .However, because the assessment of stroke in the CHARLS was mainly based on self-report, and not on detailed diagnostic criteria or specific assessment methods, the CHARLS dataset did not include clinical information about the stroke, such as type (ischemic strokes or hemorrhagic strokes), stage, severity, lesion location, or pre-stroke depression, which were therefore not analyzed.We acknowledge the importance of this issue and stress the need for caution in interpreting our findings given the limitations of the available data.Third, as this study only involved middle-aged and elderly stroke patients in China, the generalizability of our findings may be limited.
Depressive symptoms were highly prevalent in Chinese stroke patients and were associated with various factors related to demographics, family relationships, health status, and lifestyle.Our findings suggest that routine screening and assessment of depression after a stroke is necessary, and that a well-functioning support system, effective health management, and lifestyle modifications may improve depression in stroke patients.

Study design and data source
This is a national cross-sectional survey that focuses on identifying factors associated with depressive symptoms of stroke patients.This study selected samples from the China Health and Retirement Longitudinal Study (CHARLS) 2018 dataset, which includes data from 28 provinces, 150 counties and districts, and 450 urban and rural communities.CHARLS is the first nationally representative health survey of the Chinese elderly population aged 45 years and above, covering information on social, economic, and health status.CHARLS employed a multi-stage stratified Probability Proportional to Size (PPS) method for participant selection.The national baseline survey of CHARLS was conducted in 2011, and follow-up surveys have been conducted every two years since then.As of the fourth wave of data updates in 2018, the number of respondents to CHARLS was 19,816.More details regarding the survey's objectives and methods have been previously published 43 .
In this study, we included a total of 963 patients aged 45 years and older who had self-reported having had a stroke as eligible samples.In addition, it is important to note that our evaluation did not distinguish between ischemic and hemorrhagic strokes due to the reliance on self-report for stroke assessment and the lack of detailed diagnostic criteria in the dataset.

Depression measurement
Depression was assessed using the 10-item Center for Epidemiological Studies Depression Scale (CESD-10) in CHARLS.The CESD-10 measures the frequency of certain feelings or behaviors in the past week.It consists of 10 questions with four options for each question: rarely or none of the time (< 1 day), some or a little of the time (1-2 days), occasionally or a moderate amount of the time (3-4 days), and most or all of the time (5-7 days).Positive feelings or behaviors are scored as 3, 2, 1, and 0 points respectively, while negative ones are scored as 0, 1, 2, and 3 points.The total score ranges between 0 and 30 points.A higher score indicates more severe depressive symptoms.Following previous studies 44 , we used a cut-off point of 10 points.Respondents with a score of 10 or more were classified as having depressive symptoms and coded as 1, while those with a lower score were considered non-depressed and coded as 0.

Research variables
Research variables were categorized into four groups: demographics, family relationships, health status, and lifestyle.Demographic variables included age, sex, education level, marital status, and place of residence.Family relationships contained the number of children, family care, relationships with children, relationships with the spouse, and life satisfaction.Health status comprised self-rated health, health satisfaction, chronic comorbidity, physical pain, and work ability.Lifestyle consisted of drinking, smoking, physical activity, social activity, sleep duration (sleep between 5 and 9 hours was considered normal), and stroke treatment.Physical activity was measured primarily based on whether the participant engaged in vigorous, moderate, or mild activities for at least 10 min each week 45,46 .Social activities included interacting with friends, playing board games, helping family, friends, or neighbors who do not live with the participant, going to a club, participating in a community organization, doing voluntary or charity work, caring for sick or disabled adult who does not live with the participant, attending an educational or training course, investing in stocks, using the Internet, and other social activities.Participants who engaged in any of these social activities in the past month were classified into one group and those who did not were classified into another group 47,48 .

Statistical analysis
We processed the data using SPSS 22.0 (SPSS, Inc., Chicago, USA).Descriptive statistics were conducted to understand the prevalence of depressive symptoms and variable distribution.Then, the Chi-square test was adopted for univariate analysis to explore the associations of depressive symptoms with demographics, family relationships, health status, and lifestyle.Variables with P-value < 0.2 in univariate analysis were included in binary logistic regression for multi-variable analysis to further examine these associations.The results of the multi-variable analysis were presented as adjusted ORs and 95% CI.The significant level was set at 5%.

Ethical aspects
The CHARLS survey was approved by the Biomedical Ethics Review Committee of Peking University, China (approval number: IRB00001052-11015), and informed consent was obtained from all participants before conducting interviews.All research procedures were performed by the Declaration of Helsinki and other relevant guidelines and institutional regulations applied to studies involving human participants.

Variable Total Depressive Symptoms χ 2 P-value Yes No
and physical pain (OR 1.392, 95% CI 1.005-1.928)were also significantly associated with depressive symptoms.Patients with abnormal sleep tended to have depressive symptoms compared with those with normal sleep (OR 1.557, 95% CI 1.126-2.152)(Table

Table 4 .
Lifestyle and depressive symptoms of stroke patients in China.

Table 5 .
Multivariable analysis of depressive symptoms of stroke patients in China.